Is Weight Loss a Good Goal?

Most diabetes docs and educators recommend weight loss. I think that’s a losing strategy for most (not all) people. The weight nearly always comes back, bringing glucose and blood pressure back up with it. But why is sustained weight loss so difficult?

The short answer is that our bodies hate to lose weight and will do almost anything to get it back. Through our millions of years of history, the danger has always been famine and starvation. We have evolved to put on weight and keep it on, to protect against times of food scarcity. These “thrifty” genes tell us, “Rest, save energy, eat more fat. You’ll need it.” They also create insulin resistance and encourage abdominal fat deposition, to increase stores of energy for hard times.

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It appears that a few generations without hunger will turn off many of those thrifty genes for most people. Then they can eat what they want without gaining much weight, which is what happened to well-off Europeans and Asians. But for people whose families have experienced food scarcity in the last two or three generations, the genes will be turned on. This is one reason you see so much obesity among Native Americans, Pacific Islanders, and poor people of all races.

As I wrote in 2008, dieting is an artificial form of food scarcity and will activate your thrifty genes. According to the Mayo Clinic, dieting causes your body to slow its metabolism to conserve weight.

When you diet, your leptin levels will drop, or your brain will become leptin-resistant. Leptin is the chemical that tells us we’re full, so you will be hungrier as you lose weight. Dieting or exercise also makes food taste better. A French study found that even thinking about exercise makes people eat more.

Stress also seems to mimic the effects of food insecurity on our bodies. Stress increases insulin resistance and fat deposition and makes us hunger for high calorie “comfort foods.” Dieting and focusing on weight can be major sources of stress.

Weight Loss and Diabetes
So what does this mean for diabetes? We know that for overweight people with Type 2 or Type 1.5, reduced weight often leads to better glucose control, cholesterol, and blood pressure numbers. But those numbers come back up when the weight comes back. They even start to increase before the weight does in many cases. Quite probably, the weight loss isn’t helping as much as the things you are doing to lose weight — exercising, eating less, reducing stress.

To be fair, it’s not impossible to keep weight off. The National Weight Control Registry keeps track of people who have maintained at least a 30-pound weight loss for at least a year. They had 4500 people in the Registry last time I looked. According to Registry founders James Hill, PhD, and Rena Wing, PhD, about 20% of overweight and obese Americans who tried to lose weight have succeeded in keeping off a significant number of pounds.

The successful losers ate all different kinds of diets but had a few strategies in common. Nearly all ate breakfast every day. They watched very little TV. They focused more on exercise than on food consumption. They ate similar foods at similar times every day. (Of course, by doing this they were probably reducing the pleasure they got from eating. You’ll have to decide for yourself if this last one is worth it.)

This 20% success rate seems based on analyzing university-run weight loss studies, and it seems high to me. But even if it is correct, that still means 80% of dieters have gained their weight back, usually with additional pounds added.

In my view then, it’s better to focus on glucose and blood pressure numbers, and on how you feel, in the first place, and to leave weight out of the picture. It appears that no diet alone will prevent weight regain , so let’s focus on foods and behaviors that keep our blood glucose and pressure down and make us feel good, and let the weight take care of itself.

One request — please don’t go away from this article saying “David Spero says it doesn’t matter how much I eat or exercise.” That’s not what I’m saying. Eating well and exercising are important, of course! My point is that weight loss is not a good goal. Glucose and blood pressure control are. Uncontrolled blood glucose and blood pressure are the things that will damage you; and those are things you can change, so focus on them, not on weight.

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Gandhi said “Be the change you want to see in the world.” I’m not sure I understand that, but I wrote some stories about how it could work on my blog Reasons to Live.

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still too fat

David,

Thank you so much for posting this. Many of your thoughts echo my own, as I recently posted in reply to a blog by one of your fellow writers. (see below) You are literally the first person in the medical field that I have seen acknowledge an evolutionary component to obesity -and by extension diabetes, HBP, etc. And although I agree that controlling glucose and BP are imperative, I stand firmly by my assertion that someone, somewhere needs to be researching a way to adjust a person’s metabolic programming and stop blaming people for being a victim of their own genetic programming.

“No one in the medical industry seems to want to admit this, but basal metabolic rate is a genetic, not an environmental issue. Some of us simply evolved in areas where cyclical famine and starvation were common, and that evolution equipped us with biology designed to utilize calories efficiently and store the excess as fat for the inevitable famines to come. They’ve rightly observed that reduced caloric intake slows metabolism in these people, but they continue to advise diet and exercises as a cure for the very condition that dieting causes. The medical community is so married to the idea that obesity (and Type II diabetes)is caused by a lazy, gluttonous lifestyle they are unwilling to admit that it’s a genetic condition despite the mountain of evidence showing that it is. Instead we get starvation dieting, Olympic-level training programs and bariatric surgery shoved down our throats… figuratively and literally. Of the dozen or so people I know who’ve had gastric bypass or lap bands, all of them eventually gained back the weight (and more)despite their radically reduced caloric intake, because their bodies adjusted their metabolism in reaction to what it considered a prolonged season of extreme famine. Until the medical community focuses on a way of regulating metabolism rather than pushing unproductive lifestyle changes and dangerous unneeded surgery, yo-yo dieting, frustration, and the inevitable blaming of the patient will never end.”

Shelley

Hi, David. I’m a newly-diagnosed diabetic and I find your columns to be straight-talking and helpful. While I’m new at diabetes, I’m *really* experienced at being fat. I’ve been the yo-yo dieter, had weight loss surgery, obsessed over my weight for years. About 10 years ago, I discovered a different way to think about my body and my size — it’s called Health at Every Size(sm) (HAES)and it is about doing exactly what you say in your column — let’s focus on living in a healthy way no matter what your starting point. Eat the veggies because your *body* likes them and you feel better; walk the dog around the block because your body feels better. Make the body you have be as healthy as possible, even if it’s diabetic, has hyper-tension, is fat. Accept where you are now – that you are okay as you are – and then make an effort to do things that will make you feel better physically and make your body work better no matter what your weight. The relief I felt in switching the way I thought about “health” and how it applied to me, was overwhelming. And it has made my transition to the diabetic’s way of life much easier than it would have been 10 years ago. And 10 years ago I found out I could stop hating my fat self and could start really living my life as I was/am. People can get more info on HAES at http://www.sizediversityandhealth.org. Best, Shelley

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riva

I enjoyed your post and find it smart and sensible. I’m one of the 20% who has lost weight and kept it off for 30 years. And, I do most of what you said: enjoy the pleasure of healthy foods making my body fit, walk every day and eat pretty much the same way everyday. I don’t miss the sweet and fatty foods I gave up, and the occasional times I taste them now, they are so unpleasant. And yes, it took years of redirecting my goal and focusing on what I wanted – to be healthy and fit – rather than fighting the fight of losing weight.

Beth

This is for “still too fat” – I am an RN, CDE, and I have for many years taught my patients about the thrifty gene. And I learned that concept maybe 15 or so years ago at a major diabetes professional conference attended by thousands.

I myself am too fat, and have type 2 diabetes, and am descended from people who lived on farms in mountains, where food was scarce almost every February and March, so I understand on a personal level the idea that my appetite may come from my ancestors’ need to survive by storing calories in their bodies. I had to come to grips with my overweight and extend compassion to myself somehow, or I would be too depressed to do anything.

So here is how I frame it for myself and my overweight patients: Our ancestors were survivors who stored calories easly and burned them slowly. That helped them live through hard times. Now we have that inheritance, so we also store calories easily and burn them slowly, but in our time food is everywhere. But another part of the inheritance is to be a survivor! We can still do that, whether we lose weight or not. WE can find out how to live in ways that are positive. We can choose healthy foods and activities and relationships and celebrations, and so live in a way that gives us joy.

sean

I think weight loss is a good start but to say its a good idea i cant say i agree with that at all. If someone is to say diet the weight off, then get off the diet and gain all the weight back then no. If the person is going to make healthier choices to lose weight and then try for weight loss yes i think its a great start to a better life overall.

Plamen

Hi there. Reading your blog post really inspired me. I think that losing weight is hard, but unfortunately a lot of people have difficulties with this kind of problem. I will keep visiting your blog for other great blogposts. Thank you.

type1er

David
I’ve had type I for almost 35 years and I have to say that my first endocrinologist though it was ok for me to be on a starvation diet, even as an athletic teenager, to lose weight.
Needless to say, I didn’t and those early low calorie diets have probably set me up for a lifetime of frustrating and fruitless efforts to lose.
Additionally, I started pumping 10 years ago and the methods used for regulating basal rates are skipping meals. When things are tough, there are many meals to be skipped. I never lose 1 ounce during these periods and in fact, if my trouble is hidden lows (not unusual), I’ve been known to gain. It’s insane.
I do lose weight when I eat regularly…small meals 6x a day and my bg levels are not bouncing around like a ping pong ball. Then, all the stars align and the weight starts to magically fly off….I’m not talking about 1 lb a month. I’m talking like 1-2lbs a week with apparently little to no effort. Exercise or not. But, try to get your bg levels so stable without dying from food monotony or without reverting to the regimented lifestyle that pumping and modern care was supposed to free us of (perhaps some of your readers remember the days of conventional treatment when we ate to feed onboard insulin)….and when you’ve got a bg of 300 for whatever reason, even if you’re supposed to eat, who wants to?
My conclusion is that the diabetes adds several layers of metabolic stress that non diabetics will never know. It also seems to feed these so called thrifty genes. Indeed, when your metabolism cannot metabolize energy (let’s say your pump site falls off and you’re not getting insulin overnight), in addition to dealing with the probability of ketoacidosis, you are really starving….and not necessarily because of lack of food. Although, both are possible if you happen to be fasting to test a basal rate when your site falls off.
Complicated? I’ve been doing this for 35 years and I scream a resounding YES, IT’S VERY COMPLICATED. My final conclusion is that pumping gives you a tool for tighter control but it is the manual efforts of regular eating and regular times combined with regular exercise that regulate your metabolism. In other words, the diabetes treatment I learned 35 years ago at the Joslin Clinic in Boston is still more than relevant. All that has changed is the way we get our insulin….it’s a bit more flexible but it is not a replacement for the cornerstones of traditional, old fashioned diabetes management if you truly want to manage your weight and are unfortunate enough to have those thrifty genes.

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